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To the Editor:

We read with great interest the recent article by Dr. Liang and colleagues,1 showing that the proportion of U.S. seniors matching to residency positions has remained relatively stable since 1982. Studies like this help refute claims that rising numbers of unmatched U.S. seniors are evidence of an impending squeeze on the number of available graduate medical education slots.2 The reality is, since the 1950s, the United States has consistently underproduced MD medical graduates needed to fill residency positions by between 20% and 45%. And yet, despite the surfeit of positions, most U.S. seniors are still experiencing “residency placement fever,”3 applying to progressively higher numbers of residency programs in hopes of matching to their desired specialty. These two facts are difficult to reconcile; if U.S. match rates have remained relatively stable for decades, why are U.S. seniors increasingly anxious about getting residency positions?

In our work, we posit that the profession’s “social contract” with its trainees might help explain some of these puzzling trends.4 Many U.S. seniors obtaining an MD graduate with the expectation that in exchange for their hard work, debt, and deferred gratification through medical school, they will be able to pursue residency training in the specialty of their choice. In this way, U.S. seniors’ “residency placement fever” may not actually stem from a lack of residency positions nationwide but, rather, from a shortage of highly desirable positions, which, in turn, leaves many of the less desirable primary care specialties chronically understaffed. As Dr. Liang and colleagues find, unmatched U.S. seniors are less likely to rank a mix of competitive and less-competitive programs, or they rank less-competitive programs as “safety nets,” which suggests that program desirability plays a strong role in U.S. seniors’ residency selection process. We therefore need to better understand why students find some fields more or less desirable, to ensure not only that U.S. seniors match but also that residents are adequately distributed across specialties.